Provider Demographics
NPI:1114138849
Name:MEDICAL COLLEGE OF GEORGIA
Entity Type:Organization
Organization Name:MEDICAL COLLEGE OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH SERVICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTTS
Authorized Official - Suffix:
Authorized Official - Credentials:HSA
Authorized Official - Phone:706-444-1052
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31059-0224
Mailing Address - Country:US
Mailing Address - Phone:706-444-1050
Mailing Address - Fax:
Practice Address - Street 1:PRISON RD
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:GA
Practice Address - Zip Code:31081
Practice Address - Country:US
Practice Address - Phone:706-444-1052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050206261QP2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
G65629Medicare UPIN